Patients who didn't speak much, or any, English had a 35% greater chance of death.

This article was published on Tuesday, April 27, 2021 in Kaiser Health News.

By Martha Bebinger, WBUR

In March 2020, just weeks into the COVID-19 pandemic, the incident command center at Brigham and Women's Hospital in Boston was scrambling to understand this deadly new disease. It appeared to be killing more Black and brown patients than whites. For Latinos, there was an additional warning sign: language.

Patients who didn't speak much, or any, English had a 35% greater chance of death.

Clinicians who couldn't communicate clearly with patients in the hospital's COVID units noticed it was affecting outcomes.

"We had an inkling that language was going to be an issue early on," said Dr. Karthik Sivashanker, then Brigham's medical director for quality, safety and equity. "We were getting safety reports saying language is a problem."

Sivashanker dived into the records, isolating and layering the unique characteristics of each of the patients who died: their race, age and sex and whether they spoke English.

"That's where we started to really discover some deeper, previously invisible inequities," he said.

Inequities that weren't about race alone.

Hospitals across the country have reported more hospitalizations and deaths of Black and Latino patients than of whites. Black and brown patients may be more susceptible because they are more likely to have a chronic illness that increases the risk of serious COVID. But when the Brigham team compared Black and brown patients with white patients who had similar chronic illnesses, they found no difference in the risk of death from COVID.

But a difference did emerge for Latino patients who don't speak English. That sobering realization helped them home in on a specific health disparity, think about some possible solutions and begin a commitment to change.

"That's the future," said Sivashanker.

Identifying the Risk

But first, Brigham had to unravel this latest example of a life-threatening health disparity. It started outside the hospital, in lower-income communities in and just outside Boston, where the coronavirus spread quickly among many native Spanish speakers who live in close quarters with jobs they can't do from home.

Some avoided coming to the hospital until they were very sick, because they didn't trust the care in big hospitals or feared detection by immigration authorities. Nevertheless, just weeks into the pandemic, COVID patients who spoke little English began surging into Boston hospitals, including Brigham and Women's.

"We were, frankly, not fully prepared for that surge," said Sivashanker. "We have really amazing interpreter services, but they were starting to get overwhelmed."

"In the beginning, we didn't know how to act. We were panicking," said Ana Maria Rios-Velez, a Spanish-language interpreter at Brigham.

Rios-Velez remembered searching for words to translate this new disease and experience for patients. When called to a COVID patient's room, interpreters were confused about whether they could go in and how close they should get to a patient. Some interpreters said they felt disposable in the early days of the pandemic, when they weren't given adequate personal protective equipment.

When she had PPE, Rios-Velez said, she still struggled to gain a patient's trust from behind a mask, face shield and gown. For safety, many interpreters were urged to work from home. But speaking to patients over the phone created new problems.

"It was extremely difficult, extremely difficult," she said. "The patients were having breathing issues. They were coughing. Their voices were muffled."

And Rios-Velez couldn't look her patients in the eye to put them at ease and build a connection.

"It's not only the voice. Sometimes I need to see the lips, if smiling," she said. "I want them to see the compassion in me."

Adding Interpreters and Tech

Brigham responded by adding more interpreters and buying more iPads so remote workers could see patients. The hospital purchased amplifiers to raise the volume of patients' voices above the beeps and machines humming in an ICU. The Mass General Brigham network is piloting the use of interpreters available via video in primary care offices. A study found Spanish-speaking patients used telemedicine less than white patients during the pandemic.

Brigham's goal is that every patient who needs an interpreter will get one. Sivashanker said that happens now for most patients who make the request. The bigger challenge, he said, is including an interpreter in the care of patients who may need the help but don't ask for it.

In the first surge, interpreters also became translators for the hospital's website, information kiosks, COVID safety signs and brochures.

"It was really tough. I got sick and had to take a week off," said Yilu Ma, Brigham's director of interpreter services. Mass General Brigham is now expanding a centralized translation service for the entire hospital network.

Inequities Within the Hospital Workforce

Brigham and Women's analytics team uncovered other disparities. Lower-paid employees were getting COVID more often than nurses and doctors. Sivashanker said there were dozens of small group meetings with medical assistants, transport workers, security staffers and those in environmental services in which he shared the higher positive test rates and encouraged everyone to get tested.

"We let them know they wouldn't lose their jobs" if they had to miss work, Sivashanker said. And he, along with managers, told these employees "that we realize you're risking your life just like any other doctor of nurse is, every single day you come to work."

Some employees complained of favoritism in the distribution of PPE, which the hospital investigated. To make sure all employees were receiving timely updates as pandemic guidance changed, Brigham started translating all coronavirus messages into Spanish and other languages and sending them via text, which people who are on the move all day are more likely to read. The Mass General Brigham system offered hardship grants of up to $1,000 for employees with added financial pressures, such as additional child care costs.

Angelina German, a hospital housekeeper with limited English, said she appreciates getting updates via text in Spanish, as well as in-person COVID briefings from her bosses.

"Now they're more aware of us all," German said through an interpreter, "making sure people are taking care of themselves. "

Beyond the Hospital Walls

The hospital also set up testing sites in some Boston neighborhoods with high coronavirus infection rates, including neighborhoods where many employees live and were getting infected. At least one of those sites now offers COVID vaccinations.

"No one has to be scheduled. You don't need insurance. You just walk up and we can test you," Dr. Christin Price explained during a visit last fall to a testing site in the Jamaica Plain neighborhood.

Nancy Santiago left the testing site carrying a free 10-pound bag of fruits and vegetables, which she'll share with her mother. Santiago said she's grateful for the help.

"I had to leave my job because of [lack of] day care, and it's been pretty tough," she said. "But, you know, we gotta keep staying strong, and hopefully this is over sooner rather than later."

Brigham recently opened a similar indoor operation at the Strand Theatre in the Dorchester neighborhood. Everyone who comes for a coronavirus test is asked if they have enough to eat, if they can afford their medications, if they need housing assistance and if they're registered to vote.

Mass General Brigham leaders said they'll take what they've learned dissecting disparities during the pandemic and expand the remedies across the hospital network.

"Many of the issues that were identified during the COVID equity response are unfortunately pretty universal issues that we need to address, if we're going to be an anti-racist organization," said Tom Sequist, chief of patient experience and equity for Mass General Brigham.

Brigham's work on health disparities comes, in part, out of a collaboration with the Institute for Healthcare Improvement.

"There's a lot of defensive routines into which we slip as clinicians that the data can help cut through and reveal that there are some biases in your own practice," explained IHI President and CEO Dr. Kedar Mate.

"If we don't name and start to talk about racism and how we intend to dismantle it or undo it," Mate added, "we'll continue to place Band-Aids on the problem and not actually tackle the underlying causes."

"Poverty and social determinants of health needs are not going away any time soon, and so if there's a way to continue to serve the communities, I think that would be tremendous," said Price, who helped organize Brigham's testing program.

But has Brigham's work lowered the risk of death from COVID for Spanish-speaking patients? The hospital hasn't updated the analysis yet, and even when it does, determining whether (or how) the interventions worked will be hard, Sivashanker said.

"It's never going to be as simple as 'We just didn't give them enough iPads or translators and that was the only problem,'" said Sivashanker.

But Sivashanker said more interpreters and iPads, and better messaging to non-English speaking employees — plus all the other steps Brigham has taken during the pandemic — have improved both the patient and the employee experience. That, he said, counts as a success, while work on the next layer of discrimination continues.

This story is part of a partnership that includes WBUR, NPR and KHN.

Martha Bebinger, WBUR: marthab@wbur.org, @mbebinger

Health officials have been subjected to extreme scrutiny from politicians and the public over mask requirements, business closures and the extended interruption of travel and social gatherings.

This article was published on Sunday, April 25, 2021 in Kaiser Health News.

By Anna Maria Barry-Jester

SANTA CRUZ COUNTY, Calif. — Dr. Gail Newel looks back on the past year and struggles to articulate exactly when the public bellows of frustration around her COVID-related health orders morphed into something darker and more menacing.

Certainly, there was that Sunday afternoon in May, when protesters broke through the gates to her private hillside neighborhood, took up positions around her home, and sang "Gail to Jail," a ritual they would repeat every Sunday for weeks.

Or the county Board of Supervisors meeting not long after, where a visibly agitated man waiting for his turn at the microphone suddenly lunged at her over a small partition, staring her down even as sheriff's deputies flanked him and authorities cleared the room.

The letters, emails and cellphone calls that now number in the hundreds and inevitably open with "Bitch," and make clear people know where she lives and wish her dead.

And that January meeting with Santa Cruz County Sheriff Jim Hart, after the vicious mob attack on the U.S. Capitol, when he recommended to a roomful of county officials that deputies do a threat assessment at each of their homes. Newel, who'd already been through the process, casually mentioned a New Year's resolution to get more exercise and start walking to work. Absolutely not, Hart told her. She wasn't walking anywhere without an escort.

Newel, 63, is the health officer in Santa Cruz County, a picturesque string of communities hugging California's rugged Central Coast. In normal years, hers would be a largely invisible job that involves tracking measles outbreaks and STD infections, testing children for lead exposure, and alerting the public to tainted lettuce and unhealthy air. COVID has changed all that, in ways both expected and not. Newel, like health officials across the nation, has been thrust into an unwelcome spotlight and subjected to extreme scrutiny from politicians and the public over mask requirements, business closures and the extended interruption of travel and social gatherings.

Some of the dissent was understandable: the shocked response of residents asked to make unprecedented sacrifices during a time of great uncertainty. But in Santa Cruz and many other U.S. communities, legitimate debate has devolved into overt intimidation and threats of violence.

Public servants like Newel have become the face of government authority in the pandemic. And, in turn, they have become targets for the same loose-knit militia and white nationalist groups that stormed the U.S. Capitol in January, smashing windows, bloodying officers and savagely chanting "Hang Mike Pence."

Over the course of a year, Newel and her boss, Santa Cruz County's health services director, Mimi Hall, have seen their lives upended for reasons well beyond the exhausting workload that comes with battling a devastating pandemic. Their daily routines now incorporate security patrols, surveillance cameras and, in some cases, personal firearms.

They are public servants who no longer feel safe in public.

"When I do have days off, I don't want to be out in the community. I'm intimidated to be out in the community," Newel said. "I'm looking to see who might be close to me or to my car, who might be following me — looking to see if there's any kind of situation that I might not be able to get out of or that might be dangerous to me in some way."

Newel was born and raised in the city of Fresno in California's Central Valley, a region known for industrial-scale farming and conservative politics. After completing degrees in medicine and public health, Newel returned home to work as an obstetrician. There, in addition to delivering hundreds of babies, she helped develop a lactation center, a program for pregnant women with substance abuse issues and a teen pregnancy program. After 30 years of "catching babies," she'd planned to retire as a doctor's wife in Santa Cruz, where her wife, also a physician, had taken a job.

The couple call themselves Central Valley refugees; they often felt unwelcome in Fresno County as a same-sex couple. With their adult children already out of the house, they bought a home in Santa Cruz and made plans to spend the rest of their lives there. Newel felt called to serve when the health officer in a neighboring county urged her to consider a second career in public health. She became Santa Cruz County's health officer on July 1, 2019.

Newel developed an easy affinity with director Hall, who has the broader responsibility of managing all countywide medical, behavioral and environmental health programs. Hall, 53, was born in Myanmar, where her parents worked as doctors in a small hospital without running water or electricity. The family relocated to the U.S. when she was a young child. Hall has spent her entire adult life working in public health, the past 22 years in California county government. She worked in the heart of the Sierra Nevada before moving north to Plumas, a county bigger than Delaware but so sparsely populated that its county seat isn't designated a city.

There, she said, she fought with elected officials who didn't believe in her work. She said her children, among the few Asian Americans in Plumas, experienced racism and bullying. When Hall was hired by Santa Cruz County in 2018, she moved her husband and three kids to a seemingly bucolic home in the redwood forests of the Santa Cruz Mountains.

As health officer, Newel is part of a fraternity of greater Bay Area health officers who, since the early AIDS era, have met regularly to work on public health issues. Many of her local counterparts have deep knowledge of infectious diseases and, in the early days of the pandemic, she leaned on them heavily. In California, like many other states, every county is required to have a health officer. That person must have training in medicine, and, in emergencies, is granted broad authority to keep the public safe.

When Newel's Bay Area counterparts issued the first sweeping stay-at-home orders in the nation on March 16, 2020, she was just hours behind in issuing one for Santa Cruz. It ordered most businesses to close and banned most travel and social gatherings. A few weeks later, in an effort to keep tourists away, she ordered the beaches closed as well.

It was a grueling time — both Newel and Hall went months without a real day off — but adrenaline-filled. They set up testing sites, organized data-tracking operations, coordinated with dozens of state and local groups on COVID response and oversaw contact tracing for hundreds of cases.

And, as life-threatening pandemics go, they were off to a good start. Research suggests that lockdowns are most effective when initiated early, and that research is reflected in the Santa Cruz experience. Through June 2020, only a handful of people were diagnosed in Santa Cruz each week, and just two people had died from the virus in a county of 280,000, a fraction of the national death rate.

Santa Cruz County might seem an unlikely venue for menace. It's known for its laid-back vibe and hippie communes. But it's also a study in divergence: Multimillion-dollar estates are tucked into the Santa Cruz Mountains alongside the barricaded compounds of well-armed survivalists. Farmworkers tend to world-class strawberry fields in the southern part of the county alongside exclusive vacation rentals.

In the early months of the pandemic, the COVID diagnoses mostly came from south county, among agricultural workers still tending crops and living in crowded housing. The complaints, however, were mostly from people in the wealthy beach communities, and out-of-towners deeply resentful of the highly publicized restrictions.

The pushback started with angry emails and voicemails, people who contested the beach closures, the intrusion on personal freedoms. But over time, it ventured further, into language that was personal and terrorizing. Newel remembers threatening letters that stated her address and the names of her children. Others included photographs of the front and back of her home from close range, and messages like "Look out; we're coming for you." The county clerk helped scrub her address from the internet.

Hall remembers obscene late-night phone calls, and a man who seemed to be casing her home. She took her cell number off her email signature.

Then came the Sunday protesters, who would surround Newel's home with bullhorns and sirens blaring, their hostile rants making her — and, worse, her family — feel like hostages. "I'm willing to be a public servant, but I don't think that includes having people trespass onto my private property," she said. "I was quite worried for my family and for myself and our safety."

Most local health officials in the U.S. are women and, as the pandemic wore on, the threats took on a clearly misogynistic tone. People used words like "bitch" and "cunt," and made disturbing veers into sexually explicit references.

At a county Board of Supervisors meeting in late May, a young man, his voice thick with rage, accused Newel of ruining his life by closing the beaches. "You want me to stay inside, get fat, watch Netflix and masturbate?" The hearing was packed with people lobbying for a variance from state closure rules. As in previous meetings, people filmed Newel at close range. During the public comment period, they streamed to the microphone. Many removed their masks. People were visibly agitated, tapping feet, muttering swear words.

Then, a man started toward the mic, but made a beeline for Newel instead. Sheriff's deputies surrounded him and whisked Newel and Hall out of the room, while a county executive evacuated the meeting. Feeling he could no longer ensure her safety, Sheriff Hart asked Newel to stop attending meetings in person.

In the days and weeks that followed, Hall, too, adopted new routines. She would leave work at 7 p.m., when the security guards ended their shift. On her way out of her office, she called her husband, staying on the phone with him until she was locked in her car. Once home, she checked the charge on the security cameras that provide a full-perimeter view of her home and greeted her dog, who works double time as family member and security detail.

Still, she didn't know what to make of it all. "You're not sure — is it really dangerous? You feel this feeling of, well, maybe we're overreacting, you know?" Hall said.

Many of the people expressing the most vicious anger over the past year have histories of anti-government sentiment. There are the white supremacists, and groups with adopted militia names. The "sovereign citizens," who view themselves as governed only by their own interpretations of common law. The people who oppose any government mandates to be vaccinated.

Still, things accelerated during the collision of Donald Trump's presidency with the pandemic.

Membership in right-wing, white supremacist, anti-government and anti-vaccine groups was on the rise before 2020, under a Trump presidency seen as sympathetic to such ideologies and facilitated by the use of social media to draw in new adherents.

Then came the pandemic, which stranded people in their homes and transformed screens into their primary social gateways. Across chatrooms and websites, folks converged online to share grievances about perceived threats to personal freedoms. They found common cause in rebelling against closures and mask mandates and rallying around Trump. Groups that had previously protested vaccine requirements adopted militia language and imagery. Militias began organizing against health orders, and their tactics were adopted by yet more newly organized groups that formed online.

On April 17, Trump used his favored platform, Twitter, to send a series of calls to "LIBERATE MINNESOTA!" Then to "LIBERATE MICHIGAN!" and "LIBERATE VIRGINIA, and save your great 2nd Amendment. It is under siege!"

It set off a cascade of repercussions for health officials. Thousands of Facebook pages sprung up to organize against stay-at-home orders.

"They just erupted in rage at the lockdowns. [Trump] immediately undercut the credibility of public health officials," said Heidi Beirich, co-founder of the Global Project Against Hate and Extremism and an expert on militia and white nationalist organizations. "He turned the public health sector into liars and enemies of his supporters."

Public health is inherently not an individualistic endeavor. It's the science of improving the health of populations, and more often than not, those improvements are of a collective nature. To bring down rates of smoking, we've taxed cigarettes and restricted where people can smoke. Workplaces were made safer through regulations limiting exposure to toxic materials and risky machinery. Infectious diseases are slowed to a crawl through vaccination requirements.

It's not surprising that health officials would become the recipients of the backlash associated with anti-government ideologies, said Jason Blazakis, director of the Center on Terrorism, Extremism and Counterterrorism at the Middlebury Institute of International Studies in Monterey. But the country hasn't reckoned with how COVID disinformation is animating those threats.

By the end of May, health leaders across the nation were quitting in droves. In California alone, eight public health officials had left top posts, including Orange County's public health officer, Dr. Nichole Quick, who'd been given a security detail before she resigned. These were people with extensive training in public health, but also people with deep relationships in the community, the kind of expertise you can't gain in school.

Just up the coast from Santa Cruz, the health officer for Santa Clara County, Dr. Sara Cody, was receiving so many credible threats by spring 2020 that she and her family were given 24-hour security details. A series of threatening letters were particularly disturbing. They were suspected of coming from the same anonymous author because of sentence structure, but also their "misogynistic content … and clear anti-government position," a sheriff's report said. One said: "You are fucking so many for no reason … you will pay a heavy price for your stupidity bitch." Another read: "You must go no matter how you go … you stupid fucking bitch."

Santa Clara's sheriff's office began investigating.

Sheriff Hart grew up in Santa Cruz and has been with the department for 33 years. It's a rustic place without a lot of serious crime. Hart was aware of some members of white supremacist groups in the mountains, but largely considered them benign carryovers from a previous era. "I would always take threats, especially to myself and to some of our staff, with a grain of salt," Hart said. "We're in law enforcement; some people don't like us. I get that."

June 6, 2020, changed his thinking.

Seven months to the day before the siege on the U.S. Capitol, on a warm Saturday afternoon, a 911 call came into the sheriff's office. A suspicious-looking van was parked on the side of a road in the mountain town of Boulder Creek, the caller said, and it matched the description of a van used in a drive-by shooting a week earlier in Oakland, when a federal security officer was killed during a Black Lives Matter protest.

Using the vehicle identification number to determine the owner of the van, Santa Cruz sheriff's deputies made their way to his home, which was just up the road from Hall's. There, a violent ambush unfolded.

According to law enforcement reports, Steven Carrillo, an active-duty Air Force sergeant, shot at officers with a homemade AR-15-style rifle and threw at least one explosive. He fled, hitting an officer with a car. Driving the backroads, he carjacked at least one person. The brutal episode came to an end when Carrillo was tackled by a young man while attempting to steal another vehicle.

Sgt. Damon Gutzwiller, 38, was fatally shot in the ambush, the first member of Santa Cruz County law enforcement to die on the job since 1983.

Authorities have since tied Carrillo to an active state faction of the Boogaloo Bois, a secretive and decentralized anti-government movement. Unlike many of the groups pushing back against public health measures over the past year, they are expressly anti-cop. One of their stated goals has been to infiltrate Black Lives Matter protests and cause violence that will be blamed on the left, to incite a civil war. Carrillo has since pleaded not guilty to multiple charges of murder in the Santa Cruz and Oakland attacks.

Hall immediately took down the signs from her fence celebrating her daughter's graduation and declaring Black Lives Matter — anything that identified them — and installed more security cameras. "I started wondering, Who around me thinks this way? And how close are they?" Hall said.

Newel had a similar response: "Until that time, the threats seemed like nothing but threats. Like, oh, people might say these horrible things to me, but they're not going to act on them. And then that one action completely changed how I thought about my community."

Hart was devastated. He had known Gutzwiller since the deputy was a teenager. Before that day, Hart said, he realized that right-wing ideology existed but didn't understand the level of cold-blooded commitment. He started rethinking the threats to Hall and Newel. "I never thought in my career that I would see professionals, doctors being threatened for doing their job. It's been mind-boggling to me," said Hart.

A month later, Hall received a chilling letter containing references to the Boogaloo movement. It began with "Hey, CUNT," threatened her family and wished her a slow death. Similar letters had been sent to Sgt. Gutzwiller's widow and the sheriff's department.

Hart's department put out a bulletin to other law enforcement, including details of the letters and information about the man they suspected might have sent them. In neighboring Santa Clara, the sheriff's department noticed similarities to the string of letters their own health officer had been receiving since April.

When the suspect left work midday to mail yet another anonymous letter to Cody, a Santa Clara County sheriff's deputy was tailing him, according to court records. The suspect, Alan Viarengo, was arrested and charged with felony stalking and harassment of a public figure related to the letters to Cody; he has pleaded not guilty. Detectives searched his Gilroy home and found more than 130 firearms, thousands of rounds of ammunition and materials to build explosives, according to law enforcement reports.

As the criminal case moved forward, Hart suggested that, in addition to security systems, the women acquire firearms. Hall's husband came home with a shotgun. For Newel, who holds pacifist beliefs, it wasn't an option. "I wouldn't ever have a gun in my home," she said.

That same month, adherents of a sovereign citizens movement the FBI characterizes as extremist and a form of domestic terrorism went to Newel's home and served her "papers" claiming she'd broken the law. The same group, irate that Santa Cruz Police Chief Andrew Mills had supported Newel's closure orders and mask mandates, left papers inside his home, on his bedroom pillow, according to law enforcement.

Throughout these episodes, Newel and Hall were still responding to the pandemic. Even as fires raged through the mountains, forcing them to evacuate their homes. Even as they were placed on furlough to make up for budget shortfalls.

When you ask Newel and Hall about the effects of living amid so much bile and unease, both say they are not ruled by fear. But they also describe sleepless nights when their spouses are out of town, and both have withdrawn from the community. Hall stopped joining her children's school events on Zoom, afraid other parents would recognize her, and goes to the grocery store incognito, beneath a hat and messy ponytail. Newel just doesn't go out much at all.

Since last April, 22 top health officials have left their posts in California. In December, just as vaccines were arriving, Hall seriously considered resigning. She'd gained 30 pounds and started taking blood pressure medication. She was bringing her laptop into bed every night and not spending enough time with family. Her children wanted her to quit. "There were days I just felt like, I can't do this. I can't do it anymore. I can't get up tomorrow morning. I was mentally, physically, emotionally exhausted."

She has stayed, not because she thinks things will necessarily get better, but because quitting wouldn't make her life easier. It'd just teach people that if they're loud enough and mean enough they can get what they want. If she had learned anything from her refugee parents, it was that she could go on, and so she must. "It's not the idea that everything will turn out fine. It is that no matter what, you can survive this," she said.

As for Newel, she said she'll stick the job out because she's stubborn that way. But she and her wife have rethought their retirement plans. "If we don't feel comfortable being out in the community, or if we're afraid to live here, we're not going to want to stay," she said. "And that's something of a heartbreak.

This story was done as a collaboration between KHN and "This American Life." Listen to the companion audio story here.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Healthcare Foundation.

Anna Maria Barry-Jester: annab@kff.org, @annabarryjester

A growing number of insurers are quietly ending fee waivers for COVID treatment on some or all policies.

This article was published on Monday, April 26, 2021 in Kaiser Health News.

By Julie Appleby Just as other industries are rolling back some consumer-friendly changes made early in the pandemic — think empty middle seats on airplanes — so, too, are health insurers.

Many voluntarily waived  all deductibles, copayments and other costs for insured patients who fell ill with COVID-19 and needed hospital care, doctor visits, medications or other treatment.

Setting aside those fees was a good move from a public relations standpoint. The industry got credit for helping customers during tough times. And it had political and financial benefits for insurers, too.

But nothing lasts forever.

Starting at the end of last year — and continuing into the spring — a growing number of insurers are quietly ending those fee waivers for COVID treatment on some or all policies.

"When it comes to treatment, more and more consumers will find that the normal course of deductibles, copayments and coinsurance will apply," said Sabrina Corlette, research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.

Even so, "the good news is that vaccinations and most COVID tests should still be free," added Corlette.

That's because federal law requires insurers to waive costs for COVID testing and vaccination.

Guidance issued early in President Joe Biden's term reinforced that Trump administration rule about waiving cost sharing for testing and said it applies even in situations in which an asymptomatic person wants a test before, say, visiting a relative.

But treatment is different.

Insurers voluntarily waived those costs, so they can decide when to reinstate them.

Indeed, the initial step not to charge treatment fees may have preempted any effort by the federal government to mandate it, said Cynthia Cox, a vice president at KFF and director for its program on the Affordable Care Act.

In a study released in November, researchers found about 88% of people covered by insurance plans — those bought by individuals and some group plans offered by employers — had policies that waived such payments at some point during the pandemic, said Cox, a co-author. But many of those waivers were expected to expire by the end of the year or early this year.

Some did.

Anthem, for example, stopped them at the end of January. UnitedHealth, another of the nation's largest insurers, began rolling back waivers in the fall, finishing up by the end of March. Deductible-free inpatient treatment for COVID through Aetna expired Feb. 28.

A few insurers continue to forgo patient cost sharing in some types of policies. Humana, for example, has left the cost-sharing waiver in place for Medicare Advantage members, but dropped it Jan. 1 for those in job-based group plans.

Not all are making the changes.

For example, Premera Blue Cross in Washington and Sharp Health Plan in California have extended treatment cost waivers through June. Kaiser Permanente said it is keeping its program in place for members diagnosed with COVID and has not set an end date. Meanwhile, UPMC in Pittsburgh planned to continue to waive all copayments and deductibles for in-network treatment through April 20.

What It All Means

Waivers may result in little savings for people with mild cases of COVID that are treated at home. But the savings for patients who fall seriously ill and wind up in the hospital could be substantial.

Emergency room visits and hospitalization are expensive, and many insured patients must pay a portion of those costs through annual deductibles before full coverage kicks in.

Deductibles have been on the rise for years. Single-coverage deductibles for people who work for large employers average $1,418, while those for employees of small firms average $2,295, according to a survey of employers by KFF. (KHN is an editorially independent program of KFF.)

Annual deductibles for Affordable Care Act plans are generally higher, depending on the plan type.

Both kinds of coverage also include copayments, which are flat-dollar amounts, and often coinsurance, which is a percentage of the cost of office visits, hospital stays and prescription drugs.

Ending the waivers for treatment "is a big deal if you get sick," said Robert Laszewski, an insurance industry consultant in Maryland. "And then you find out you have to pay $5,000 out-of-pocket that your cousin didn't two months ago."

Costs and Benefits

Still, those patient fees represent only a slice of the overall cost of caring for a hospitalized patient with COVID.

While it helped patients' cash flow, insurers saw other kinds of benefits.

For one thing, insurers recognized early on that patients — facing stay-at-home orders and other restrictions — were avoiding medical care in droves, driving down what insurers had to fork out for care.

"I think they were realizing they would be reporting extraordinarily good profits because they could see utilization dropping like a rock," said Laszewski. "Doctors, hospitals, restaurants and everyone else were in big trouble. So, it was good politics to waive copays and deductibles."

Besides generating goodwill, insurers may benefit in another way.

Under the ACA, insurers are required to spend at least 80% of their premium revenue on direct healthcare, rather than on marketing and administration. (Large group plans must spend 85%.)

By waiving those fees, insurers' own spending went up a bit, potentially helping offset some share of what are expected to be hefty rebates this summer. That's because insurers whose spending on direct medical care falls short of the ACA's threshold must issue rebates by Aug. 1 to the individuals or employers who purchased the plans.

A record $2.5 billion was rebated for policies in effect in 2019, with the average rebate per person coming in at about $219.

Knowing their spending was falling during the pandemic helped fuel decisions to waive patient copayments for treatment, since insurers knew "they would have to give this money back in one form or another because of the rebates," Cox said.

It's a mixed bag for consumers.

"If they completely offset the rebates through waiving cost sharing, then it strictly benefits only those with COVID who needed significant treatment," noted Cox. "But, if they issue rebates, there's more broad distribution."

Even with that, insurers can expect to send a lot back in rebates this fall.

In a report out this week, KFF estimated that insurers may owe $2.1 billion in rebates for last year's policies, the second-highest amount issued under the ACA. Under the law, rebate amounts are based on three years of financial data and profits. Final numbers aren't expected until later in the year.

The rebates "are likely driven in part by suppressed healthcare utilization during the COVID-19 pandemic," the report says.

Still, economist Joe Antos at the American Enterprise Institute says waiving the copays and deductibles may boost goodwill in the public eye more than rebates. "It's a community benefit they could get some credit for," said Antos, whereas many policyholders who get a small rebate check may just cash it and "it doesn't have an impact on how they think about anything."

Julie Appleby: jappleby@kff.org, @Julie_Appleby

The Pfizer-BioNTech vaccine comes in 1,170-dose packages at minimum and expires after five days in a fridge, meaning too many doses on too tight a deadline for many rural communities to manage.

This article was published on Friday, April 23, 2021 in Kaiser Health News.

By Katheryn Houghton

As states expand COVID-19 vaccine eligibility to allow shots for 16- and 17-year-olds, teens in rural America may have trouble getting them.

Of the three vaccines authorized in the U.S., currently only one can go to that age group: the Pfizer-BioNTech shot. That vaccine comes in 1,170-dose packages at minimum and expires after five days in a fridge, meaning too many doses on too tight a deadline for many rural communities to manage.

"We're still trying to get people to accept the vaccine," said Aurelia Jones-Taylor, CEO of Aaron E. Henry Community Health Services Center, which serves remote regions of the Mississippi Delta. "If we have to race to give out 1,100 doses in five days, that's untenable."

Some health experts say vaccinating children — more than a fifth of the nation's population — is key to ending the pandemic. In the meantime, pressure is mounting to get vaccines out as health officials flag more surges of cases, this time with more contagious variants that seem to affect kids more than the initial virus strain that coursed through the U.S.

"The infection can continue to spread until we get everyone in the population vaccinated, and that includes younger individuals," said Gypsyamber D'Souza, an epidemiologist with Johns Hopkins Bloomberg School of Public Health.

The logistical challenges of eventually getting the shots to rural kids of all ages will likely continue, at least in the short term. That's because the companies behind the sole vaccine with approval for 16- and 17-year-olds, Pfizer and BioNTech, have also been the first to seek federal approval to vaccinate younger ages after a trial showed the vaccine was effective in kids 12 through 15 years old. Pfizer spokesperson Steve Danehy said the company hopes to win regulatory approval for that age group before the start of the next school year.

For some families, the shots are so coveted that they'll travel whatever distance it takes. Dr. Jeannette Wagner Waldron, 45, of Park County, Montana, said the closest place she was able to find a vaccine for her 17-year-old daughter, Julie Waldron, was Billings, which meant a nearly four-hour round trip to a CVS pharmacy there for the teen's first shot.

"I'm more than willing to drive two hours to get my kiddos vaccinated," Wagner Waldron said. "They've given up a lot, from their activities and seeing their friends, in order to protect people from the virus."

Not everyone can travel that far for vaccines once, let alone twice to get both doses. Compound that with some reluctance in rural communities to get vaccinated at all. A recent KFF survey showed a larger share of rural residents — 21% — said they wouldn't get a COVID vaccine compared with urban and suburban respondents. That could mean not enough remaining demand for vaccines to use up a 1,170-dose Pfizer package in rural communities. Even if the demand exists, rural health departments may not have enough workers to administer the doses fast enough.

Karen Sullivan, health officer for the Butte-Silver Bow Health Department, said Butte will serve as the main vaccine base for 16- and 17-year-olds across five counties in southwestern Montana that together cover as much area as all of Maryland. She said she's worried that delivering Pfizer shots to each community could risk wasting doses, but her department may make a new plan if too many people can't get to Butte.

Health officials there have been trying to convince teenagers and their guardians the shots are safe and worth traveling for since Montana opened COVID vaccines to everyone 16 and older April 1. Butte-Silver Bow's new vaccine campaign includes sharing photos of the area's school mascots getting the jab and raffle prizes for those who get vaccines.

"What we're trying to do is get ahead of the variants," Sullivan said. "We can't get our 16- and 17-year-olds vaccinated fast enough, in my mind."

Finding Pfizer vaccines can be challenging even in cities, which serve as medical hubs for rural communities. To help with that, some providers have set up online COVID vaccine registration systems specifically for 16- and 17-year-olds, such as one through Stanford Children's Health for clinics around San Jose, California.

In Mississippi, Jones-Taylor said her center hopes to reach kids through school-based and mobile outreach clinics. But she said that depends on either the Moderna or Johnson & Johnson vaccine, each of which have minimum shipments of 100 doses, gaining regulatory approval for minors. Both manufacturers are testing how their shots work in children.

The Children's Health Fund, a national nonprofit, has advocated for the "continued urgent inclusion of children of all ages in vaccine trials" and for prioritizing a single-dose, easy-to-store vaccine.

Dr. Cody Meissner, a pediatrician on the vaccine advisory committee for the Food and Drug Administration, questions the rush to extend the vaccines to younger ages without more time to study potential impacts, adding that children so far have been less likely to transmit the virus or die from an infection.

The debate over whether to vaccinate younger kids as a means to end the pandemic may soon be moot, though, said Dr. Monica Gandhi, chief of the Division of HIV, Infectious Diseases and Global Medicine at the University of California-San Francisco. She pointed to a recent study out of Israel — a nation ahead of the rest of the world in its vaccine effort — which showed that infection rates declined even without immunizing children younger than 16. That study has yet to be peer-reviewed.

"We may get to herd immunity without vaccinating all kids," Gandhi said. "But as long as it's a safe vaccine, the more people that get it, the more people that develop immunity, the better."

Back in Park County, which has a population of fewer than 17,000, health officials have seen an increase in COVID cases among younger people in recent weeks, some tied to middle and high school sports.

Dr. Laurel Desnick, county health officer, said the county set up vaccine clinics in high schools by working with the state and neighboring counties to split up a shipment of Pfizer vaccines, though that took time to organize. Until mid-April, the county directed 16- and 17-year-olds like Julie Waldron to a county more than 100 miles away for a shot.

"Some of our kids could do it, but not all," Desnick said. "The further you are from a big center, the harder this gets. We're rural, but we're also not as remote as many of the central or eastern Montana counties, and I feel for them."

For Ava Braham, who turned 16 two days before Montana expanded eligibility to her age, a vaccine clinic in her Park County school means she missed only 20 minutes of class to get her shot this month instead of having to drive more than 50 miles round trip over a mountain pass.

"The biggest thing for me with the vaccine is being able to see my family more often. Both of my grandparents have already gotten the shot, but I will feel more comfortable visiting them," Braham said. "It's sort of a moral obligation to help the whole country and the world to just get the shot."

Katheryn Houghton: khoughton@kff.org, @K_Hought